Letter by Yang and Bai regarding article, "Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis".

Letter by Yang and Bai Regarding Article, “Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis” To the Editor: We read with interest a recent article by Tsivgoulis et al on the safety of intravenous thrombolysis (IVT) in stroke mimics (SM). Through both their own institutional data and meta-analysis of 8 published series, the authors found a low risk of symptomatic intracranial hemorrhage among SMs receiving recombinant tissue-type plasminogen activator (tPA). Because tPA does not adversely affect the favorable natural history of SMs, the authors argued that delaying IVT to rule out a stroke mimic is not warranted in terms of safety. The decision to treat a patient with IVT for acute ischemic stroke (AIS) is often based on the patient’s medical history, clinical presentation, laboratory test results, and computed tomographic (CT) findings because of the limited time window thrombolysis is feasible for AIS. As a consequence, there will always be some patients treated with tPA who have no ischemic stroke but another medical condition mimicking a stroke. Because tPA has been proven safe in these patients, can we accept SM as unavoidable when managing suspected AIS? The answer is no because tPA is an unnecessary, inefficient, and potentially harmful treatment. It is also expensive, especially for patients who have to pay out of their own pockets. In light of this, we would like to ask the following questions: